SECTORAL DEBATE 2005 PRESENTATION BY HON. JOHN JUNOR, MINISTER OF HEALTH ON MAY 11, 2005


In many ways, the nation’s health took centre stage during the Financial Year 2004-5, not only for the Ministry of Health, but for various individuals, organizations and groups, as they focused on the sector.
And rightly so.Because the fact is, that issues of health usually mirror many of the conditions we face. which, left untreated, could become emergencies or become chronic. So we welcome this focus, as it helps us to identify and refine the issues and establish priorities for action. To a large extent therefore, the Ministry had to both be introspective and innovative in addressing the issues and garnering the resources necessary to keep the sector afloat, with minimum interruption and ensure that its health operating systems were adequately fuelled, to deliver health care at an acceptable standard. For this we are grateful for the partnerships that we were able to forge with our public and private sectors, and the continued support of regional and international organizations like the World Health Organization (WHO), Pan American Health Organization (PAHO), the Global Fund, UNICEF, USAID, the EU and the World Bank.
Let me say without hesitation, that we have a team of health workers in this country that is second to none. The health team has been reliable, resourceful, resilient and has produced outstanding results, despite the challenges and I wish to thank them on behalf of our Government and our people, for the service they continue to give to our country.
In September 2000, 189 world leaders at the UN Millennium Summit adopted the Declaration committing their nations to stronger global efforts to reduce poverty, improve health and promote peace, human rights and environmental sustainability. The eight Millennium Development Goals (MDG) that emerged, are specific, measurable targets, aimed at achieving shared development goals and reducing extreme poverty which still grips over 1 billion of the worlds people. In this vision for global action six of the eight goals speak directly to health. The document has therefore become the blueprint for our reform efforts and provided the benchmarks for development of our own goals, programmes, standards and regulations. Consistent with the MDG the Ministry is focusing on ensuring gender equality, reducing child mortality, improving maternal health, combating HIV/AIDS and other diseases, ensuring environmental sustainability and developing global partnerships for health.
Having successfully reduced the impact of infectious diseases, and mindful of new and emergent infectious diseases, such as West Nile Virus and SARS, the Ministry has moved from a pre-occupation with these conditions, to embracing the new challenge – that of lifestyle conditions, based on the current trends. In 1999 the Disease Burden in terms of mortality, showed that the 5 leading causes of death were
Vascular diseases Cancer Accidents and Violence
Diabetes Mellitus Hypertension
The promotion of healthy lifestyle practices is therefore a major plank of the Ministry’s strategy to reduce the disease burden, and achieve the goal of optimum health for all.
The health sector benefited tremendously from the initiatives of the previous year, that saw two pieces of landmark legislation, paving the way for the establishment of the National Health Fund (NHF) – an innovative concept that brought new life to the sector, and the Child Development Agency (CDA) – the embodiment of hope and a new deal for our children, especially those in residential care.
It was a year in which the Ministry sought to re-define, streamline and accelerate the health reform process, which started in 1997, with the promulgation of the Act establishing Regional Health Authorities and starting the process of decentralizing our health services.
The Year was not without challenges Mr. Speaker, but I am pleased to report that we rose to every occasion, thanks to our dedicated, committed and professional staff. whether it was the screening and provision of health and preventive care for the over 877 of our Haitian brothers and sisters, who have landed on our shores since February 2004, the onslaught of Hurricane Ivan, which put our Emergency Management System to the test, or dealing with the results of that event, which caused significant loss and damage within the sector.
I express my gratitude to the Hon. Prime Minister for his leadership and the confidence he has entrusted in me over the years and to my Cabinet and Parliamentary Colleagues, my constituents and colleagues in the political process, whose unwavering support has been a source of strength in helping me to function effectively, as Minister of Health and M.P. – To the Permanent Secretary Chief Medical Officer and the staff of the Ministry, who continue to advise and guide – to the Chairmen and boards of the respective the Regional Health Authorities and RDs, RTDs and their staff, who in challenging times continue to meet service levels.
To the professional staff – doctors, nurses, pharmacists, technicians, public health staff, Administrative and technical staff and ancillary – to Dr. Holness and staff at RGD, Ms. Allison and staff at CDA, Mr. Barrett and staff at NHF, Mrs. Kerr and staff at Health Corporation Ltd., Councils, Mr. Tucker and staff of the NCDA and to the twenty odd professional groupings with which we interact. I say thanks.
I must also thank my wife Urla, my children, grandchildren, family and friends for their love, loyalty, understanding and support, which have enabled me to devote myself to serving our country in this way.
Mr. Speaker, I believe the country is aware that by choice, I will not have a very long time left to offer my contribution, at this level of national life.
Today, I will therefore present something of a Report Card of Performance, especially over the last few years of my tenure as Minister of Health .I intend to share with you the Vision for Health as we see it, our progress to date in making it a reality. even as we review and refine the process. and more importantly, point to the solid foundation that has been laid to secure the good health and well-being of Jamaicans in the future. And therefore, Mr. Speaker, I now report on the status of the health sector 2005, using a SWOT Analysis framework
THE STATE OF THE NATION’S HEALTH
Strengths
In assessing Jamaica’s health status in 2005, Mr. Speaker, we find that Jamaica has maintained excellent health standards when compared to both developed and developing countries, including the United States, Canada and the United Kingdom. The 2004 PAHO Report on Basic Indicators shows that Jamaica’s life expectancy at birth is 76.1 years. This compares to 77.4 for the USA, Barbados 77.5, for Canada 77 and Trinidad 71.1. The report also highlights our efficiency in delivering service based on expenditure – what we have been able to do to, despite constraints, to maximize our resources. So in terms of positive health indicators, Jamaica is right up there among the best.
Within the context of decentralization, The Ministry’s primary role is that of monitoring and regulating the health sector, as well as providing leadership and policy guidance for the four Regional Health Authorities.
Our health team comprises groups of professionals in their field, who are well qualified, experienced and adaptable.
There is a strong emphasis on public health through a network of health centres. Secondary and tertiary care hospitals add to the facilities that enhance access to health care. The health care system is further strengthened by the partnerships, which exist at both the corporate, and NGO level, as well as at the community levels.
Our Health profile is therefore positive…
Weaknesses
While the MOH is providing leadership, there are gaps in the implementation of policies and programmes. These often result in a fall-out in programme delivery, which compounded by situational factors, can contribute to slippages in some critical indicators. For example, the present low immunization coverage is due to a number of factors, implementation issues such as shortage of public health nurses and transportation, supply of vaccines and environmental issues including Hurricane Ivan, violence in some areas, and surprisingly. a lack of interest on the part of parents to ensure that children are immunized. This is cause for concern and we are moving quickly on this to ensure that we do not lose ground…
There are challenges relating to human resources, in terms of the “old cadres” developed in the 1970s, and outstripped by increasing demand for services in the public sector, as well as chronic shortages, in that cadre and chronic shortages in critical areas, such as pharmacy, radiology, assistant nurses, midwives… Some physical facilities are in need of repairs and refurbishing, and our fleet of both ambulances and service vehicles are in need of urgent upgrading.
Service delivery has been affected by population growth, and demographic shifts, which often render facilities inadequate or under-utilised.
Issues related to biomedical and diagnostic equipment, as well as pharmaceutical supplies, continue to plague us.
Resource constraints – financial, human, physical, and the high cost of providing health care, in a world where technology increasingly plays a critical role and where that technology is not cheap.
Opportunities
Our response to the challenges has been to adopt an integrated approach to development, which seeks to collaborate and consult with the range of stakeholders in health and to ensure that health outcomes drive our policies and programmes and creatively address the weaknesses. There is the opportunity to complete the decentralization process by reorganising the Head Office and reorient the service to meet the needs.
There are also opportunities for innovative solutions, to mobilize resources to adequately meet the needs of the health system, as well as facilitate upgrading, and retooling of the plant and enhance and modernize our systems. The fact that there is public interest and a heightened sensitivity to health and lifestyle issues provides us with fertile ground in which to plant the seeds for good health and longer life for all
Threats
These include
The rapid rate of increase of the HIV/AIDS epidemic
The Avian influenza and other zoometric conditions
Re-emerging diseases – such as TB, Polio
Losing the gains of previous years, in terms of control of infectious diseases because mothers/parents are, for whatever reason, refusing to immunize their children
Global issues, such as trading arrangements that reduce ability to access medicinal products, or that could lead to deterioration in our economic and social conditions and so affect our ability to provide proper housing, safe water, adequate nutrition, all of which are determinants of health.
International pull factors, that affect the migration of skills We have sought to manage these issues in a holistic way, based on a consistent vision of health, which recognizes the centrality of the individual.
A VISION FOR HEALTH
While the mission of an organization – its raison d’etre – is at the core of its mandate and essentially remains the same. The vision can, and must adapt and change to meet new and varying circumstances.
Our vision for health is one which sees a health system that is client-centred, guarantees access to quality health care for every person in our population, at reasonable costs, and which takes into account the vulnerable among us. It is based on the concept of individuals taking responsibility for their own health and adopting healthy lifestyle habits, within a clean, healthy environment where families and communities actively participate and are integrated into the system of health…
The country expects, and we are committed to a health system in which all the players have a shared vision for maintaining good health and the shared value of preventing ill health. A system that is goal oriented, all inclusive, equitable in treatment and access and that delivers service of the highest quality and facilitates wellness. a system based on the premise of the individual’s right to health information and ensuring that people have every opportunity to make informed choices that will determine health status. Ultimately, Mr. Speaker, we in this Parliament, must ask ourselves, what kind of citizen do we wish to create in our country. And I suggest that simply, our collective goal must be to create individuals who can make responsible and reasonable choices on issues that affect their lives, regardless of whether it is health, education, economic pursuit or recreation.
How do we address the weaknesses and threats to our health status?
Having identified them, let me now turn to solutions to the present dilemmas and address the foundation being laid to secure the future.
MOBILISING RESOURCES
FINANCING HEALTH
Financing health care has pre-occupied Governments for many years. In the present climate, it has been a significant challenge and we have had to devise innovative schemes to address the issues. While there are no easy solutions, one strategy that has worked and which continues to facilitate health care delivery is that of partnerships with our stakeholders. This was particularly evident in the Post-Hurricane Ivan period, and The Ministry and the health services in general, wish to acknowledge the support, especially for programmes.
One of our main assets has been the relationship with WHO/PAHO and their link with the UN network and other international sources of funding. Last year alone, PAHO was able to provide assistance to the tune of J$127M (including $45M in Hurricane Relief). It is through PAHO that programmes such as, immunization, nutrition/breastfeeding, public education for issues like Tuberculosis are undertaken.
Much of our effort to date in addressing HIV/AIDS, has been facilitated through a loan from the World Bank . In 2003 a Grant of US$23M over the next five years, was approved from the Global Fund to support increased interventions. US$3.9M was spent in the 04/05 financial year.
The United Nations Children’s Fund (UNICEF) has continued to sponsor our efforts aimed at improving the lives of our children – from birth, to early adolescence.
The Health Budget this year reflects reduced reliance on the Government and increased financing options. Our overall budget J$12.08 billion – broken down as follows Recurrent $11.5 B Capital A J$50 M Capital B. J$533.8 M
The figure for 2004 was J$13.575B (including $2.5B for Statutory Deductions which is not applicable this year) the Actual budget for 2004 was therefore $11.075 net, actually less than this year. There were major increases in Health Service Delivery from 9.72B in 2004 to J$10.2B this year. Children’s services came in for a big increase from J$550M in 2004 to J$850M this year, and Bellevue received an increase from J$443M to J$540M this year. THE NATIONAL HEALTH FUND
With the passage of time, Mr. Speaker, the merits of the legislation establishing the NHF are becoming more evident. The NHF has been a significant and important source of financing for the health sector in the year just ended, and because it provides two levels of benefits – institutional and individual – it has touched the lives of all Jamaicans, and made a real difference, in its first full year of operations.
The Board of the NHF was appointed in February 2004, and together with the management and staff of the Fund has laid the foundation for the development of a strong organisation, which is fulfilling its mission to reduce the burden of health care in Jamaica.
Mr. Speaker, I would like to use this opportunity to publicly commend the NHF for attaining ISO 9001:2000 Certification. This means, that the NHF in this short time, has been certified by the International Organization for Standardisation, as having a world-class quality management system that delivers service of the highest standard to its customers.
An efficient management system is the key to the NHF’s delivery of benefits to individuals and institutions. You will recall that The National Health Fund provides two categories of benefits:
NHF Individual Benefit that provides subsidies for persons of all ages, for specified pharmaceuticals used in the treatment and management of chronic illnesses and including the Jamaica Drugs for the Elderly Programme (JADEP) that provides drugs free of cost, for persons sixty years and over.
Institutional Benefits which provide for the entire population, through grants to public and private sector entities for health promotion and illness prevention as well as public sector projects to improve infrastructure.
During the year the NHF increased membership for its Individual Benefits Programme to approximately 60,000 persons (NHF subsidy for all ages) and absorbed some 100,000 persons on the JADEP programme. This was achieved through targeted promotions at 112 events, advertising campaigns, community health days and other customer service initiatives.
The Healthy Lifestyle Survey 2001 revealed that only a quarter of the persons who are aware of their chronic illness are actively treating their conditions. This amounts to approximately 180,000 persons for the Chronic conditions covered by NHF. In this early wave, the persons who have enrolled with the NHF (160,000 beneficiaries) belong to this group and efforts are being made to increase enrolment in the NHF Individual Benefits programme through a number of activities. This includes the introduction of Customer Service Agents for a six month period in Hospitals and Health Centres across the island, to ensure continued enrolment of persons with chronic conditions.
When the NHF was established, about 500 prescription items were on the Individual Benefits Drug List. In November 2004, an additional 250 prescription items were added, on the recommendation of the Medical Review Committee of the Board.
I am pleased to announce plans for another major expansion in the benefits provided by the National Health Fund. A new condition, Benign Prostatic Hyperplasia (enlarged prostate) will be added to both programmes – JADEP and the NHF- once the necessary approval process is complete. High Cholesterol will also now be included in the Jamaica Drug for the Elderly Programme, and hence the number of illnesses covered under JADEP now moves to ten conditions. In addition, new drugs are being added to the JADEP Drug list for existing conditions, increasing the number of items covered by JADEP by almost 100 percent from 38 to 72 prescription items.
Under the JADEP programme persons sixty years and over obtain their medication free of charge. A fee of up to $40 per item may be charged by the pharmacist for dispensing a month’s supply of the drugs on the JADEP Drug List. Approximately $56m was spent for subsidy claims and drugs for JADEP during the year. Adding Benign Prostatic Hyperplasia to the NHF Drug List brings the number of conditions covered by that programme to fifteen.
One factor that is important to the success of the programme, is the pharmacy network. The efforts of the NHF together with the demand by NHF beneficiaries for pharmacies accepting NHF health cards have resulted in a significant increase in the number of pharmacies contracting with the NHF. There are now 220 public and private sector pharmacies island-wide providing service to beneficiaries and their claims are paid within 10 working days of receipt of such claims, approximately 95% of which are electronic.
The majority of pharmacies contracted to the NHF have demonstrated a commitment to serving NHF beneficiaries and consistently fulfil the obligations of their contract and have gone further to promote the benefits of the NHF to their clients. An important clause of the contract between the NHF and participating pharmacies is the auditing of the NHF claims made by participating pharmacies. “The Fund or its duly authorized Agent shall be permitted during a providers regular business hours and upon giving the provider 3 days prior notice to undertake periodic inspections of beneficiaries records and other documents relating to pharmaceutical benefits which have been supplied by the provider.”
During the financial year over 145 audits were conducted. Generally participating pharmacists have been co-operative but there has been some resistance -in that pharmacists are concerned about the confidentiality of customers’ records. While the NHF Act speaks to the need for such audits we will have to move to the next level, which is to establish Regulations to strengthen the Act – such as giving inspectorate
There are several obligations of participating pharmacies. Pharmacies for example who contract with the NHF to provide JADEP services must dispense all the drugs on the JADEP List. These pharmacies also have a responsibility to the NHF to ensure that they are properly stocked with JADEP drugs by ordering replacement stocks on a timely basis. And we also ask that NHF participating pharmacies endeavour to have their systems up to date, to facilitate efficient service to NHF beneficiaries.
Doctors are an important part of the team, as they can assist in the Registration and monitoring of patients. On the other hand NHF beneficiaries have a responsibility for managing their health care costs and should not be afraid to shop around for the best prices for their prescription drugs and for the best service.
The NHF also made significant grants on a project basis only, to institutions in the public and private sectors, to improve the delivery of health care. The NHF Institutional Benefits component started in April 2004. Since then, sixty seven (67) project requests have been received, 63 from public sector entities and 4 from the private sector. Forty seven (47) of these projects have been evaluated, forty-five (45) have been approved at a value of $1692 million.
The Ministry of Health has been the recipient of the largest grant to date, to support training of health professionals in 53 areas. Among the most critical categories are entry level nurses, midwives, pharmacists, environmental health officers, nutritionists and dieticians, radiation technologists and cytologists. The grant also facilitated re-opening of the Spanish Town Midwifery School, where training of the first group of midwives commenced last month, with 23 direct-entry students.
Other projects approved include IT improvements for public sector pharmacies, research development, civil works in public sector facilities, Health promotion activities, e.g. healthy lifestyle, immunization, environmental health, vehicle acquisition and equipment purchase.
The NHF is a marvellous success story of this administration, that is impacting positively on the lives of Jamaicans of all walks of life and I urge my colleagues in this House to encourage our constituents with the chronic conditions listed, to enrol for NHF Individual benefits and to support health facilities in the development of appropriate project proposals to the NHF.
There have been suggestions that the elderly have difficulties in registering for benefits…
For JADEP persons can self-report their illness for registration, there is no need for Doctor’s certification, only proof of age (accepted forms of Identification) and no TRN.
For the NHF it is necessary to have more formal means of Identification to reduce instances of abuse.
BALANCING THE COST OF CARE
Mr. Speaker, as you can see, the net has been widened to pull in as much financing as is available to fund our health services. However, as you can imagine, the cost of providing care and delivering services, including supplies, equipment and maintenance is often prohibitive. This year, we therefore had to increase the contribution made by users of our services (which is a small portion of what it costs us to provide the service), in order to keep the services going and not compromise care. Fees collected for fiscal year 2004-5, represented only 11.6% of the actual cost of service. And just to give you an idea of the contribution let me illustrate, based on a study conducted in 2003.
The economic cost for one “In-Patient Day” varied from J$2,723 per day for paediatric care, to $4,112 per day for General Surgery, while the current Fee charged is $500 per day.
The economic cost for an outpatient visit J$1,891, while the current fee is $300In most cases, private sector costs are significantly higher 2 – 5 times more
The Ministry is very aware of the plight of those who are unable to meet the cost of care and consistent with the Millennium Dev. Goals, mechanisms have been put in place to facilitate access to care for all. So even as we state the case for co-payment, our facilities have not turned away anyone because of inability to pay, and in fact, this is the reason our efforts at collection have been less than successful. We continue to appeal to those who can, to pay the fees. We also appeal to members of the house who are aware of any persons who have been unable to access services to report to the Ministry of Health. Let me however declare, that not all procedures can be covered by the Ministry. In cases where persons may have some catastrophic health challenge, other means will have to be sought. Persons will also be asked to meet the cost of drugs not covered on the Ministry’s VEN list (Vital Essential Necessary) or appliances that are not available. For those who can’t meet the cost of care , various Government Ministries and agencies are working together in a kind of “joined-up Government” effort to facilitate the needs of the vulnerable groups. For e.g. The Ministry of Labour & Social Security has a rigorous selection process to identify PATH beneficiaries, who automatically receive free services from our hospitals and health facilities. The MOH is working with the MOLSS to access the Social Safety Net Database, for the pilot of a Beneficiary Identification Score (BIS), for User Fees Waiver of up to 50% for the quintile above PATH, in 10 hospitals – KPH, Bustamante, Victoria Jubilee, Spanish Town,, St. Anns Bay, Annotto Bay, Cornwall Regional, Sav la mar, Mandeville and May Pen. And I am pleased to say, Mr. Speaker, that this collaboration will identify these persons, for additional health benefits, and other options to ensure that everyone has access to health care. This pilot project is being funded by the IDB as part of its Technical Cooperation Grant to support the government’s Social Safety Net Reform.
Other programmes such as NI GOLD, which is a health insurance scheme administered by Ministry of Labour and Social Security and Blue Cross for retired NIS Pensioners..as well as the Jamaica Drug for the Elderly Programme outlined earlier, also cater to the same age cohort, by facilitating access to pharmaceuticals.
Health Corporation Limited is another vital link in the chain. The company has been making pharmaceuticals available at sometimes, as much as 50% less than the prevailing rates. The strategy of international tendering, buying in bulk and using contracts resulted in a savings to Government last year of J$67M. while savings of J$114M was generated on the basis of the differential between the awarded prices and the next lowest responsive bids. The chain of DrugServ Pharmacies (9 pharmacies in 7 parishes) dispensed approximately 238,411 prescriptions last year and a survey showed that prices were 74% below those in retail pharmacies. We plan to expand this service over the next two years. POST -HURRICANE IVAN RECOVERY
The Health Sector suffered significant loss from the effects of Hurricane Ivan. Of the 24 hospitals, 21 or 88% suffered damage. Annotto Bay, Black River and Percy Junor were badly damaged, with repairs estimated in the region of J$50M. Of the 343 health centres, 128 were affected and some could only provide limited service. USAID provided a Grant of J$70 million for the reconstruction and recovery effort for these primary care facilities.
The CHASE Fund contributed J$25.5 towards the rehabilitation of Annotto Bay Hospital, while the NHF provided over J$118M for repairs to this and other secondary care facilities (hospitals), including Black River, and Percy Junor. Recently the Jamaica Stock Exchange contributed J$3M for rehabilitation of the roof of the Sir John Golding Centre. To date the sector has received over J$237M for financing hurricane reconstruction.
We must also thank Cable & Wireless Jamaica and Capital & Credit Merchant Bank for donations of generators to the National Blood Transfusion Service at Slipe Road and National Chest Hospital and the Sir John Golding Centre. ..as well as corporate giants like Scotia bank, which has consistently contributed to health by building and maintaining the Accident and Emergency Units in a number of Hospitals.
The Indian Government also contributed a supply of pharmaceuticals to the relief effort valued at J$12M. HUMAN RESOURCES
A Health service that is inadequately staffed is like a body without vital organs, as people are integral to the system. To address the critical shortages, a total of 313 professionals were recruited during the year, that includes 115 doctors, 113 Registered Nurses, 85 Enrolled Assistant Nurses. While the Ministry is somewhat constrained in terms of matching the human resource needs to existing “cadres”, we are reviewing these in the context of new and emerging diseases, as the modalities of offering care have changed significantly…
But, Mr. Speaker, Our concern is not only with numbers, as we must ensure both quantity and quality, so that our professionals can remain at the cutting edge of their field – hence the importance of training and exposure to health systems in the global community. The NHF is injecting capital of J$365M to revive the training of health professionals and significant emphasis is being placed on critical areas of need, e.g. the training of nurses, mid-wives, pharmacists, to meet the demand. Over J$101M has been allocated to the training of nurses, e.g. Meanwhile, the Ministry has been pursuing a policy shift by transferring all basic nursing training/education programmes to the Ministry of Education. Arrangements have been made for internships for critical care overseas. Other groups targeted for training include pharmacists, pharmacy technicians, environmental health officers and Information Technology.
The Ministry continues to support doctors for the Doctor of Medicine Programme which is a post graduate course offered by the UWI, with clinical support from Hospitals in the South East Region .i.e. KPH, BHC, VJH, Bellevue and UHWI. This facilitates Post Graduate training of doctors in all disciplines of medicine and the programmes range from 4-6 years. At the end of the period the doctors are qualified for appointment as consultants in the disciplines in which they were trained. There are now 36 persons in the programme, which cost the Government J$1.656 million per year. Over the last three years, twenty five consultants graduated, nine in 2002 and eight in 2003 and 2004.
Changes have been agreed by the Medical Councils of the region, to reduce the internship to 12 months, with an additional two years of supervised clinical experience, before a doctor is eligible to practice independently. This has implications for employment in the public sector, and will require the establishment of common guidelines as well as a mechanisms for monitoring the process. At the completion of the two years rotation, persons will have to make way for new intake into the system. Only if vacancies exist, can there be an expectation of permanent employment.
The Ministry also reintroduced this year, professional training for Nutritionists and Dieticians in the form of the Internship Programme, which had not been in place for a number of years.
HEALTH REFORM
In 1997, the historic National Health Services Act was passed, giving legal status to the regional health authority. This was the first phase of a process of decentralization of the Ministry of Health, which should have continued with a restructuring and streamlining of the Head Office, to reflect the changes and re-assignment of some responsibilities to the health authorities.
Essentially the RHAs were set up to manage the delivery of health care – primary, secondary and tertiary – in the four regions.the South East, Southern, North East and Western, as semi-autonomous units of the Ministry of Health, with their own Boards and management teams. They operate based on Service Level Agreements with the Ministry, which aim to standardize service, across the board.
The RHAs have been achieving commendable service levels, despite the constraints, and just to highlight a few …
Southern Region (Clarendon, Manchester, St. Elizabeth
The Wellness ProgrammeSuccesses in Cataract Surgery at the Mandeville Hospital
South East (Kingston, St. Andrew, St. Catherine, St. Thom as)
The reorganization of operations at KPH based on a Business Centre concept
A Re-branding effort at the National Chest Hospital as the first cardio-pulmonary rehabilitation out-patient’s suite in the English speaking Caribbean.
Piloting new Food Safety Measures and Food Handlers Permit
Partnerships that facilitated Paediatric Open Heart and Eye Surgeries at the Bustamante Hospital for Children
North-East (Portland, St. Ann, St. Mary)
Refurbishing of the Operating Theatre and establishment of Microbiology Lab at St. Ann’s Bay Hospital
Managing the health issues related to Haitian Refugees in Portland
Western (Hanover, St. James, Trelawny, Westmoreland,)
Refurbishing of Accident and Emergency Unit at Savanna la mar Hospital
Refurbishing of the morgue at Cornwall Regional Hospital
Strengthen STI/HIV Programme
Establishing Epidemiology Unit at the Cornwall Regional Hospital
At Head Office we are strengthening the policy and institutional framework to facilitate monitoring, establishing standards and health services planning, developing a communication policy and procedures manuals to guide quality assurance.
Mr. Speaker, my presentation would be incomplete, without mention of some of our key programmes and service delivery areas for which we have responsibility
HEALTH INITIATIVES- PROGRAMMESHEALTHY LIFESTYLE POLICY
Years of attention to preventive care, i.e. immunization and environmental health have paid dividends. Chronic Non Communicable Diseases (CNCDs) – diabetes, hypertension, heart disease and obesity; the stark reality of HIV/AIDS, as well as injuries and deaths from violence and motor vehicle accidents are the main challenge. These have therefore been the focus of the Ministry’s efforts in recent years, and precipitated a major policy change in terms of health promotion, and in the case of HIV/AIDS – prevention and treatment for persons living with the disease.
Mr. Speaker, last year, we tabled in this House, a “National Policy for the Promotion of Healthy Lifestyles in Jamaica”. I am advised that it is the first of its kind in this hemisphere. By way of a reminder, the policy aims to increase our awareness of the major risks to maintaining good health, i.e. diet, lack of exercise, tobacco use, unhealthy sexual practices and aggressive behaviours.
On the point of quitting tobacco smoking, Mr. Speaker, the Ministry, with the help of PAHO and the International Research Centre, commissioned a survey on the Economic impact of tobacco interventions on tobacco consumption in Jamaica. The results of that research show a positive co-relation between timely interventions and reduced consumption, and we know that the Minister of Finance embraced those results. Jamaica is working towards early ratification of the WHO’s Framework Convention on Tobacco Control (FCTC). And we are now looking at cost-effective tobacco control measures, for example, such issues as smoking in public places. We also plan to step-up our public education activities, to heighten awareness of the harmful effects of this anti-social behaviour.
The Healthy Lifestyle Programme aims to reach Jamaicans where they are – in schools, workplaces and in communities, for example:
Among adolescents the approach is to use a fun and creative initiative in the form of a “Cheerleading” contest and healthy lifestyle clubs. The Cheerleading Programme targeting High School Students, started in 2003 and encourages physical activity and concern for the environment.
Community interventions include developing safe, green, spaces that can be used for physical activity, recreation and the facilitation of health interventions. The Ministry and the RHAs have been working with communities to establish these areas. Yesterday, May 10 – was observed as “Move for Health Day” and one such “Healthy Zone” was launched at the St. Ann’s Bay Oval Sports Complex, where a walking/jogging trail and exercise benches were established and health messages mounted. Other Healthy Zones are due to come on stream in May, at Sheffield in Westmoreland and Hamilton Gardens in Portmore. More communities are encouraged to transform or expand sports fields to Healthy Zones where young and old can exercise and improve their health.
Wellness Centres
In the Southern Region (Manchester, Clarendon and St. Elizabeth), a wellness programme has been piloted with support from the Japanese International Co-operation Agency.(JICA), where clients are screened at the centres and counselling done for four targeted lifestyle conditions, i.e. cardio-vascular disease, hypertension, diabetes and obesity.
Workplace “Wellness” programmes are being pursued as a way of integrating healthy habits into the work place
Approximately two years ago the Ministry of Health launched a series of health festivals to promote healthy lifestyles. Perhaps one indication of our success is the proliferation of such festivals and the increasing focus within the society on healthy living. This is a good sign.
HIV /AIDS
HIV/AIDS poses the most serious threat to health in Jamaica today and our approach to the disease must be one of aggressive interventions, both to prevent its spread through education of the populace and to facilitate treatment and access to care for Persons Living with HIV/AIDS (PLWHA). Figures for 2004 suggest that close to 1100 new AIDS cases have been reported to the Ministry. A marginal increase of less than 4% registered compared to the previous year.
Results of a “Knowledge Attitude Practice and Behaviour (KAPB) survey” done in 2004, indicates that there is a significant increase in knowledge and awareness and individual sexual practices, compared to 2000.. There is significant reduction in myths surrounding the HIV/AIDS disease. More people are now taking responsibility for protecting themselves from HIV infection. , however, some people are not practising safe sex, for a variety of reasons. Generally men demonstrate more consistent protective sexual behaviour compared to women in high risk sex.
The National STI/HIV Prevention and Control Programme and its partners made significant progress in 2004/2005 budget year; in scaling up the prevention and care interventions to reduce the spread of HIV in the general population. These include increasing condom usage by sexually active men and women, promoting abstinence, treating STIs, the provision of anti-retroviral drugs for over 800 persons living with HIV/AIDS and providing access to Voluntary Counselling and Testing (VCT) to all pregnant women attending the public health services- The HIV testing is confidential and is undertaken with the informed consent of the individual and ensured access to ongoing counselling and access to treatment. It is estimated that 65% of PLWHA do not know their HIV status (that they are HIV infected) , and so we will be expanding HIV testing. A VCT site exists in all major Health Centres in the parishes and at all Antenatal Clinics (ANC). These clinics are currently screening 90% of ANC attendees (28,000 in 2004 compared to 4,000 in 2002) and over 50% (19,000 in 2004) of STI Clinic attendees. HIV testing was also decentralized in all parishes with the introduction of rapid HIV test at each care site, as well as building capacity in four health regions to confirm HIV test results without sending blood samples to the National Public Health Lab (NPHL) in Kingston.
In the past we have lamented the lack of focus on the treatment, care and support for persons living with HIV/AIDS. Now, thanks to the grant received from the Global Fund, to which I made reference earlier, the Ministry has been able to increase and improve service to persons living with HIV/AIDS. Fifteen specialized treatment centres have been established in the Regional Health Authorities and 12 are functional. At these treatment sites PLWA are assured of a national basic standard of care including screening and diagnostic services, counselling, psychological and social support, provision of specialized clinical care and improved access to life saving anti-retroviral medications.
Up to September 2004, anti-retroviral therapy was accessible only to those who could afford and to a limited number of individuals who could be supported in the public sector though donations mainly from LASCO pharmaceuticals. However, by the end of June 2005 ARVS will be provided for up to 1000 PLWHAs who have advanced stages of the HIV disease. Our goal is to have universal access program of ARV drugs to all PLWHA who needs the treatment. Continuing medical education of physicians and other health care workers is also being implemented, in order to manage combination schemes of drugs appropriately. Medical management guidelines are currently being distributed.
The monitoring of ARVS distributed to Pharmacies and clients is being done through a partnership with the NHF. This will see the NAP utilizing the existing NHF database for drug management, resulting in each client on ARV treatment being given an NHF card. This card will be identical to NHF cards for all other conditions and will allow PLWHAs to access their medication in a confidential manner. This is expected to come on stream by August 2005.
Our next steps include providing Policy and legislative framework as well as expanding the prevention intervention by 10 fold.
National HIV/AIDS Policy – which was launched yesterday, May 10
Workplace HIV/AIDS Policy
Reducing and eliminating HIV related Stigma and Discrimination
meeting the targets set through the declaration of commitment by UN General assembly on HIV/AIDS
VIOLENCE AND ROAD ACCIDENTS
The health system bears the brunt of the burden of intentional and unintentional injuries. Jamaica’s homicide rate , at 45 per 100,000 in 2004, is among the highest in the world. The cost of violence on our health Care System and the society in general has been significant, requiring urgent and consistent attention. As a result, Violence Prevention has been identified as a critical component of the National Policy for the Promotion of Healthy Lifestyles in Jamaica, and the MOH is undertaking and facilitating several programmes and interventions to reduce the scourge of violence and prevent the propagation of violent acts/activities.
One response has been the design of a Violence-Related Injury Surveillance System in collaboration with the US Centre for Disease Control (CDC), the University of the West Indies, the Tropical Metabolism Research Institute and the Kingston Public Hospital where it was added to the existing Patient Administration System and piloted in 1998. The system has since been expanded into the Jamaica Injury Surveillance System (JISS), which tracks both intentional and unintentional injuries including motor vehicle accidents and attempted suicides, and operates at nine of the eleven computerized hospitals across the island.
Another is the formation of the Violence Prevention Alliance (VPA) – Jamaica Chapter – a network of organizations (public and private sector) working to prevent violence. Launched in November 2004, VPA takes a public health approach to violence prevention, addressing root causes and looking at support for the victims of violence.
VPA is part of a collaborative effort with the Peace Management Initiative (PMI), Social Development Commission (SDC), Area Youth Foundation (AYF), the Girls Brigade and the Community Relations Branch of the Jamaica Constabulary Force to implement a number of interventions at the Community level, focusing on the Mountain View Area as a pilot project. This includes “healthy lifestyle” activities such as health screening and NHF Registration; a community cultural programme spearheaded by AYF, training through the Girls Brigade, backyard gardening and a parenting programme.
The latest initiative by VPA is the production of a booklet “Raising Children to Resist Violence” (which should be in your package) which targets parents, teachers and care-givers to teach non-violence to children.
There is also a hospital- based intervention at the Bustamante Hospital for Children. Camp Bustamante utilizes a small group of social workers to intervene in cases of abuse and violence against children. Intervention includes home and school visits, referral to other agencies safety audits and counselling sessions. This programme began in January 2004, and during the year 396 cases of physical and sexual abuse were identified and are being managed by the team. The Ministry intends to scale up this intervention to other hospitals across the island in the near future.
FAMILY HEALTH
A major focus of the MOH has been on decreasing the Maternal Mortality Rate (MMR), as we strive to achieve the MDG for maternal health for Jamaica. The expectation as I noted then, was to reduce our maternal mortality rate to 27 per 100,000 by 2015. The target last year was to decrease the rate from 106 per 100,000 by 10% to 95 per 100,000 live births. The target was met.
And this was achieved as a result of training of health staff including training in the use of partographs (instrument to monitor the progress of labour). These instruments are now being piloted in four regional hospitals. In addition all parishes now have weekly high risk Anti Natal Clinics (ANC) run by Obstetricians.
The challenge now is to further reduce the MMR to achieve the MDG of 27 per 100,000 by 2015. Central to reducing the maternal morbidity and mortality and peri-natal mortality is increasing the attendance of skilled health personnel for every birth. In this regard, the opening of the new midwifery school at the Spanish Town Hospital is a strategic move to increase the numbers of midwives coming into the system, and hence increases the attendance of skilled health personnel for every birth.
In terms of immunization, a “Mop Up” programme is now underway, to immunize all babies and children under two who have not been fully immunized. And, Mr. Speaker, we are determined, even if we have to use the strength of the law to get parents to comply. Because we do not believe that parents understand the danger they pose to their children’s lives and to the society without immunization.
CHRONIC DISEASES
Substantial amounts of the health budget are utilized in providing medical care for chronic diseases and focusing on the improved management of these conditions remains a priority for the MOH.
A number of interventions were piloted including an audit tool for measuring the quality of care being offered to clients with diabetes and hypertension.
An intervention aimed at reducing re-admission rate and length of stay for patients with diabetes and hypertension was conducted at a Kingston based hospital. It included discharge planning, telephone follow-up and visitation. Results show that there was less re-admission to hospital among patients in the intervention compared to the control group. The intervention will be expanded to other hospitals in 2005.
The thrust for 2004, in collaboration with the Jamaica Cancer Society, was to increase pap smear screening among women in the 25-54 years age group, especially those who had never done a pap smear. Cervical cancer is preventable, treatable and curable and training programmes were conducted in all parishes, to update knowledge and standardize procedures for pap smears, as well as materials and supplies to improve the capacity to offer screening services.
A review of the collection and retrieval system for pap smear slides was conducted at the National Public Health Laboratory (NPHL) and modifications were done to improve the system. As a result there have been improvements in the reading of slides – the turn around time is now shorter, all slides are read on schedule and reports of positive cases sent out immediately.
I now wish to point, very quickly, to some of the solid achievements in recent years
MAJOR ACHIEVEMENTS
Landmark pieces of legislation – Child Development Act, National Health Fund which saw the establishment of the Child Development Agency and the National Health Fund
Significant work on the Rights of the Child and the reorganization of services for children
Citizens Charters for our health service
The MOH supported the JASPEV programme in terms of the social safety net such as the expansion of the Jamaica Drugs for the Elderly Programme and services and collaboration under PATH
Improvements in Information Technology – computerization of records in a Patient Administration System, and piloting the teleconferencing of Regional Performance reviews
Quality Assurance Programmes – protocols for infection control, treatment of major chronic diseases,
Client-centred Health Care Delivery
Health Sector Modernization – introduced the concept of Clinical Effectiveness
Staff Welfare/Spiritual Wellness Programmes
New approach to Resource Mobilisation for the health sector
A landmark Healthy Lifestyle Policy and a HIV/AIDS Policy
THE NEXT STEPS
MOH Strategic Priorities 2005/2006
Mr. Speaker, earlier we highlighted areas for urgent attention in the system and our approach to these is now, solution oriented. Our strategy for 2005/06 and beyond is to close the gaps, reduce the impact of the threats and build on our strengths for a solid foundation in health. An exercise in reconfiguring the health services is underway. This will forecast our human resource need based on the new structures. We have begun to utilize the approach of cross functional teams to reduce silos and improve the flow of information within and without the sector. The establishment of the long awaited National Advisory Committee in November 2004 is one way of achieving this.
Continue the Health Reform process by, commencing the Reorganization/Reconfiguration of the Ministry of Health (Head Office) into a more policy focused organization. This is set for completion by December 2005 and will include revamping the Communication Policy to facilitate and streamline some of the operational and monitoring issues.
We will begin the reorientation of the public Health Services (primary and secondary/tertiary care) to make it more responsive to addressing the country’s health needs and specifically the Disease Burden. This will take the form of a pilot/phased roll-out in four hospitals, starting 2005/06
The Ministry is currently exploring a potential financing source from Europe to fund projects to improve the public health infrastructure and provide medical equipment.
Completion of a User Specifications document, this is the first step in the process of identifying a suitable Computerised Health Information System. This should facilitate improved management at all levels of the organization especially patient management.
Completion of a study of the Ministry’s Pharmaceutical Services, the recommendations from this study will be used to improve the management of pharmaceutical and medical supplies.
Work on reconfiguring the National Public Health Laboratory will continue, approval has been given for the Steering Committee to conduct a Prior Options Review, which should be completed in this fiscal year.
The role of Child Development Agency will be strengthened and in keeping with the Child Care and Protection Act, the Child Advocate will be put in place.
Planned Customer Service training will improve the quality of Clinical Services provided.
A new Service Level Agreement between the Ministry of Health and its Regional Health Authorities will be signed this fiscal year. This document functions in a similar fashion to a contract and will guide the relationship between the parties, for the next three years.
The threat of new and re-emergent diseases linked to global trade will propel our need for regional collaboration and a greater focus on international health. As we plan the future.
I appeal to each citizen to assume responsibility for their own health and join us in the vision for health.
Mr. Speaker, I take my seat, confident that the vision has been articulated, the strategies outlined and a solid foundation has been laid for good health and a secure future for the people of Jamaica.
APPENDIX 1
The National Health Fund
List of Approved NHF Institutional Benefits Project
INSTITUTIONAL BENEFITS: PROJECT APPROVED BY NHF
APRIL 2004 – MAY 2005 PROJECT # PROJECT TITLE APPROV. DATE BUDGET HSF01 Food Handlers Badge System & Health Departments Computerisation 15/6/04 $16,387,776 HSF02 Cornwall Regional Hospital (CRH) Rewiring & Communication System Upgrade 15/6/04 $16,750,438 HSF03 Latrine Sanitation (Black River Health District) 15/6/04 $1,731,613 HSF04 Port Maria Hospital Phase 2 Renovation 15/6/04 $1,500,000 HSF05 Purchase of Premises for the offices of the SRHA 15/6/04 $66,950,000 HSF07 Highgate Health Centre 15/6/04 $42,155,000 HSF08 Public Health Inspectors Equipment 15/6/04 $10,448,110 HSF09 Information Technology Infrastructure Upgrade (SRHA) 15/6/04 $14,646,667 HSF10 Cornwall Regional Hospital Power Factor Correction 15/6/04 $4,200,000 HSF12 Cornwall Regional Hospital & Residential Quarters Roofing Repairs 15/6/04 $13,500,000 HSF13 Cornwall Regional Hospital Windows Replacement 15/6/04 $21,000,000 HSF16 MOH Environmental Needs 21/09/04 $11,453,083 HSF17 Training Support for C. McFarlane (MOH) 28/07/04 $1,000,000 HSF18 Issac Barrant Health Centre 19/10/04 $12,398,298 HSF19 Prostate Cancer Diet & Lifestyle Factors 19/10/04 $12,082,862 HSF20 Edna Manley Health Centre (Relocation) 19/10/04 $4,678,561 HSF20a Edna Manley Health Centre (Rebuilding) 19/10/04 $43,500,000 HSF21 Training – Disease Prevention & Control 19/10/04 $810,000 HSF22 Scholarship – Natural Resource Management 19/10/04 $150,000 HSF23 May Pen Hospital Structural Repairs 19/10/04 $41,650,000 HSF24 Vehicles – National Public Health Lab 7/12/04 $4,750,000 HSF25 Vehicles For MOH EOC – Post Ivan 16/11/04 $5,000,000 HSF26 Training of Health Professionals 16/11/04 $200,000,000 HSF27 Radiographic Cassette Replacement 5/1/2005 $10,699,899
APPENDIX 2
National Council on Drug Abuse
Achievements 2004:
The National Council on Drug Abuse (NCDA) through its community groups and collaborative agencies promoted prevention education for the year 2004. Activities included
The adoption of life skills as an approach to prevention, with structured activity management, job creation, entrepreneurial activities as alternatives to drugs
Promotion of substance abuse programmes in public and private sector companies especially in vulnerable sectors where public safety and security was at stake. The NCDA also focused on treatment and rehabilitation and is in the developmental stage for a new group of officers – substance abuse specialists for community treatment and rehabilitation.
Public education as a major part of drug abuse prevention education was also a focus. The delivery of a unified message in drug abuse prevention by all agencies that provide family life education and health promotion and the development of a culturally sensitive public education programme
Projections for 2005
For 2005 the National Council On Drug Abuse will focus on
Prevention Education: through
Community Groups to reduce substance abuse dependence and other high risk behaviour;
Promotion of early childhood psychological interventions to prevent substance abuse;
The adoption of a life skills approach to prevention;
The promotion of structured activity management, job creation, entrepreneurial activities top drug activity;
The establishment and strengthening of programmes in public and private sector companies,
Public Education:
Delivery of a unified message in drug abuse prevention that provide family life education and health promotion;
Development of a sensitive public education programme
Treatment and Rehabilitation: (Adolescent and Children)
Development of specialist treatment programmes for the community treatment of all children and adolescent substance abusers;
Islandwide detoxification treatment facilities for substance abusers;
Prevention and treatment programmes in prisons (a collaborative effort of the Ministry of Health, the NCDA and the Department of Corrections);
Drug Court:
The strengthening of the Diversion of Point of Arrest system for substance abusers through the Drug Court;
Projects:
new research projects to inform Public Education Programmes and evaluation/surveys
development of sentinel sites;
training of health professionals;
development of interventions targeted at specific groups with the aim of changing behaviours;
expansion of the Information Centre (Special Library);
targeting parents through Parent Teachers Associations;
targeting low literacy youth through Project Squeaky;
targeting workplaces with prevention and treatment programmes for drug abusing staff.
Human Resource Development:
The development of a competent and motivated cadre of employees that will achieve the agencies objectives;
APPENDIX 3
Registrar General’s Department
Performance Summary
Key Performance Indicators
At the end of the 2004/2005 financial year The Registrar General’s Department achieved an 90% success rate. Of the 58 Key Performance Indicators (KPIs) used during the period to assess the Agency’s performance 52 KPIs were favourable in surpassing or meeting their targets while 6 were unfavourable.
Highlights include:
Delivery of Certificates
One strategy was ‘door-to-door” delivery of certificates. Delivery was made to 242, 115 customers of the 261,450 applications received for the year 2004/2005.
Applications Received vs. Applications Printed
A total of 288,089 applications were received for the 2004/2005 financial year of this total at March 31, 2005, 261, 450 were printed.
Application Tracking System and Online Query system
The Customer Online Query System (COQS) and the Application Tracking System (ATS), implemented in the last financial year, continued to provide easy access to information on the status of applications. The Agency received several commendations from customers who were able to track their applications online through the RGD Website and complaints have decreased.
Information Systems support and BDMS Version Three
BDMS 3 was implemented during the third quarter of the 2004/2005 financial year and Internal demonstration of the completed Application Tracking System. In terms of IT support, a helpdesk software (HelpStar) was installed and deployed internally.
Regional Offices
In January 2005 the RGD opened three new regional offices in Santa Cruz, Port Antonio, and Sav-anna-la-mar, this brings the total number of regional offices to seven.
The South East Regional Office (Half Way Tree office) which is currently the largest regional office was relocated in the first quarter to a more spacious and convenient location at 4 Trevennion Park Road Kingston 10.
Vital Statistics
During the second quarter of the financial year the agency conducted sub-audit of birth and stillbirth registrations occurring in hospitals. Using the Spanish Town hospital as the testing facility, an RGD representative was given the mandate of capturing all births and stillbirths that occurred at the Maternity Ward of the Spanish Town General Public Hospital. The contact with this hospital continues to ensure that all vital events are reported to RGD.
The agency was pleased to present the completed 2002 Vital Statistics Report and the provisional reports for 2003 and 2004 to the Executive Director of STATIN. In keeping with the agency’s mandate to provide vital statistics for stakeholder groups, the RGD has produced an electronic central vital statistics database, which is accessible to select stakeholders through the website.
The preliminary figures for total registrations for the year 2004/2005 indicate that for the period April to September 2004, 20,913 vital events were registered. The calendar year figures indicate that for January to September a total of 63,474 registrations were collected. 34,401 of this number related to live births, 10,978 were deaths, 462 stillbirths, 288 infant deaths, 17,521 were marriages.
Recording of documents
A Bill of Sale project was implemented during the fiscal year. This project sought to:
Determine the number of Lending Agencies that submitted
Identify those companies that are not complying with Section five (5) of the Bills of Sale Act.
Identify companies that no longer submit Bills of Sale to IRO and the reasons.
Educate companies on their responsibilities to “Enter Satisfaction” when an obligation under a Bill of Sale has been discharged.
Total documents recorded by the Island Record Office at the end of 2004/5 were 22, 844.
Public Education
RGD embarked on its 2004 North American Outreach. July 10 – 26, 2004. Cities in Florida, Georgia, Washington, New Jersey, Toronto and Montreal were visited and presentations were made to over five hundred Jamaican emigrants. A total of 964 local outreaches were conducted during the year. Major Plans 2005/6 include
The redevelopment and re-launch of the agency’s website,
vital data capture project.
Online Registration from Registration Centers
Online Payment Options
APPENDEX 4
Child Development Agency
The Child Development Agency (CDA) continues to pursue reform measures to enhance the welfare of Jamaica’s children, in keeping with the Child Care and Protection Act of 2004, which seeks to address the issues of Child protection in a holistic manner
Work is moving apace for the establishment of the Office of the Children’s Advocate and the Children’s Registry.
Monitoring Officers have been employed and are serving a vital role in the monitoring of child care facilities
60 new Children’s Officers assumed duties on 2 May and will be assigned across the island to ensure the deliver of quality service
CDA is reorganising the structure of Children’s Services and has renamed the positions of superintendents of the homes and places of safety to Managers, in keeping with the emphasis on management and quality service.
Recruitment of these Mangers has recently been completed
CDA will put in place a maintenance schedule to ensure proper upkeep of facilities
Government recently approved increase for the maintenance of children in private institutions. Retroactive rates were paid from January 2005 and certainly this will enhance the quality of care.

JIS Social